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ligated. Systemic heparin was administered at 100 IU/kg (1mg/kg). [Variation: The first set of intercostal vessels below the

coarctation were suture ligated and divided.] All intercostal vessels expected to be within the clamped area were

controlled with atraumatic snares [Variation: The ductus arteriosus was suture-ligated]. The proximal aortic arch, left

carotid artery, and left subclavian artery were clamped with a Castaneda-type vascular clamp. The descending thoracic aorta

was clamped below the level of the coarctation. The coarctation segment was excised. All ductal tissue was removed. The

proximal aortotomy was extended onto the undersurface of the distal aortic arch to a point just opposite the distal left common

carotid artery. The descending aorta was spatulated appropriately and then a long, sliding, extended end-to-end anastomosis

was carried out with a fine running polypropylene suture. Prior to completing the suture line, the aorta was de-aired with

heparinized saline solution. The suture line was completed. The vascular clamps were sequentially removed and the snares

on the intercostal vessels were removed. There were excellent pulsations in the descending thoracic aorta. After the

completion of the anastomosis the blood pressure gradient between upper and lower extremities was assessed and there was

no significant gradient. Hemostasis was assured. The posterior mediastinum was irrigated with warm antibiotic saline

irrigation. The pleural edges were reapproximated using running polypropylene suture. A [BLANK] French chest tube was

placed through a separate incision and secured to the skin. The lung was re-expanded. The rib edges were reapproximated

using interrupted absorbable pericostal sutures. Serratus anterior fascia, latissimus dorsi muscle, and subcutaneous tissue

were reapproximated using running absorbable suture. The skin edges were approximated using a running absorbable

subcuticular stitch. Dermabond skin adhesive was applied. The patient tolerated the procedure without complications. He/She

was transported to the Pediatric Cardiac Intensive Care Unit in a satisfactory condition.

The aortic cross-clamp time was [BLANK] minutes. All instruments, sponges and needles counts were confirmed to be correct

x 2 at the end of the case.

Dr. [BLANK] was present and scrubbed for [BLANK] elements of this operation.

Suggested Readings:

1. Khonsari S, Sintek CF. Cardiac Surgery: Safeguards and Pitfalls in Operative Technique. 4th ed. Philadelphia,

PA: Lippincott Williams & Wilkins; 2008, p 209-217.

2. E. L. Bove and J. C. Hirsch. Surgery for Congenital Heart Defects by J. Stark and M. de Leval, VT Tsang. John

Wiley & sons, Ltd; 2006, p 285-298.

3. Kaiser, Larry R.; Kron, Irving L.; Spray, Thomas L. Mastery of Cardiothoracic Surgery, 2nd Edition. Lippincott

Williams & Wilkins; 2007. P 769-778

4. Backer CL, Kaushal S, Mavroudis S. Coarctation of the Aorta. In: Mavroudis C, Backer CL (eds). Pediatric Cardiac

Surgery, 4

edition. Wiley-Blackwell; 2013, p 256-282.

11. Division of Vascular Ring

Wissam Raad, MD, MRCS

1,2

and Samuel Weinstein MD, MBA

1, 2

1. Montefiore-Einstein Center for Heart and Vascular Care, New York, NY

2. Albert Einstein College of Medicine, New York, NY

Essential Operative Steps

1. Lines and Monitoring

2. General endotracheal anesthesia

3. Appropriate positioning

4. Posterolateral thoracotomy

5. Identify aortic arch and descending aorta

6. Identify subclavian and carotid vessels, confirm presence of the ring

7. Confirm ligamentum arteriousm or patent ductus, if present

8. Divide the ring

9. Free the esophagus from adhesions

10. Chest tube

11. Close ribs, approximate the chest wall in layers

Potential Complications and Pitfalls

1. Avoid injury to the neurovascular bundle upon entering the chest

2. Identify and avoid injury to the vagus nerve

3. Identify and avoid injury to the recurrent laryngeal nerve

4. Avoid injury to the esophagus

Template Dictation

Preoperative Diagnosis: Vascular ring [INDICATION – e.g. stridor, dysphagia]

Postoperative Diagnosis: Same

Procedure(s) Performed: Division of vascular ring (DETAILS – e.g. PDA ligation)

Attending Surgeon: [BLANK]

Secondary Surgeon: [BLANK]

Assistants: [BLANK]

Anesthesia: [BLANK]

Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. increasingly

worse stridor and shortness of breath]. Preoperative CT scan or echocardiogram reveals [FINDINGS - e.g. a descending right

aorta with a rightward ductus] or barium swallow reveals [FINDINGS - e.g. posterior indentation of the esophagus].

Description of Procedure: After informed consent the patient was taken to the operating room on [DATE]. The patient’s

identity and planned procedure were verified, and the patient was placed on the operating room table in a supine position.

General anesthesia was induced. A right/left internal jugular central venous line and a right/left radial arterial line were

inserted. The patient was then turned to the right/left, an axillary roll was placed underneath to protect the axilla and to prevent

brachial plexus injury. We then proceeded to prep and drape the chest in the usual sterile fashion. A time out was performed.

The right [Variation: in case of left arch and right ductus] or the left [Variation: in case of double arch with left-sided

ligamentum, or in case of a right arch with retroesophageal component] chest was opened through a posterolateral thoracotomy.

The latissimus dorsi was divided partially. Electrocautery was used for hemostasis. The serratus anterior muscle was spared,

and the fourth intercostal space was entered. The lung was held anteriorly with stay sutures.

Variation: Right aortic arch with retroesophageal component. The descending aorta, ligamentum and vessels were all

identified after opening of the chest. The ligamentum was mobilized from around the esophagus and divided. Clamping of this

vessel does not result at all in blood pressure change in the arterial line in the left subclavien artery, and there is no change in

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the blood pressure cuff in the left arm. The vessel was then divided and ligated. Upon division it was obvious that there was

ductal tissue within the structure. After division of the vessel the esophagus is relieved of the tethering. The incidental

adhesions were taken down further to allow mobilization and freedom of the ring.

Variation: Left aortic arch and right sided ligamentum arteriosum. The descending aorta on the right was easily

encountered. The vessels branching from the aortic arch were mobilized and identified. There was an additional vessel that

leaves the aorta medially opposite the right subclavian branch and enters the pericardium towards the pulmonary artery. This

vessel encircles the esophagus and there is obvious tension upon it. This vessel was mobilized and was temporarily clamped.

Clamping of this vessel did not result in blood pressure change in the arterial line in the left subclavien artery, and there was

no change in the blood pressure cuff in the right subclavian artery. Temporary clamping of the right subclavian artery does

result in a blood pressure change in the blood pressure cuff in the right arm. The vessel was then divided and ligated taking

care to avoid injury to the recurrent laryngeal nerve. Upon division it was obvious that there was ductal tissue within the

structure [Note: This is the usual case for a vascular ring]. After division of the vessel the esophagus was relieved of the

tethering. The incidental adhesions are further taken down to allow mobilization and freedom of the ring.

Variation: Double arch with left-sided ligamentum arteriosum. The atretic arch was easily identified after the thoracotomy.

The arch vessels were identified from each limb of the aorta, and the posterior limb of the aorta was seen descending behind

the esophagus. The arch was then divided between clamps close to its junction with the descending aorta to maintain patency

of the arch vessels. Both ends were oversewn with two rows of 4-0 polypropylene sutures. Tissue bands were then divided

away from the trachea and esophagus.

The ligamentum arteriosum is divided, taking care to avoid injury to the recurrent

laryngeal nerve.

A Marcaine block was given to the intercostal region. A 16-French straight chest tube was placed, and the ribs were

approximated with #1 Vicryl. The remainder of the chest wall was closed in layers in the usual fashion. The fascia was then

closed with #1 Vicryl suture in a running fashion. The deep dermal layer was then closed with #2-0 Vicryl suture in running

fashion. The skin and subcuticular layer was closed with #3-0 Monocryl in running fashion. The skin of the wound was

cleansed with sterile saline and dressed with antibiotic ointment and a sterile dressing. All instrument, sponge and needle

counts were confirmed to be correct x 2 at the end of the operation. The patient was subsequently transferred to the

postoperative pediatric cardiac surgical intensive care unit in critical condition.

Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.

12. Pulmonary Artery Banding

Raghav Murthy MD., Vinod Sebastian MD.

Children’s Medical Center of Dallas, Texas.

Essential Operative Steps

1. Lines and monitoring.

2. General endotracheal anesthesia.

3. Median sternotomy.

4. Total/subtotal thymectomy.

5. Ligation of patent ductus arteriosus, if present.

6. Dissection of the pulmonary artery from the aorta.

7. Placement of band at the proximal pulmonary artery.

8. Depending on the specific lesion being palliated, adjustment of the band until the pressure distal to the band is 1/3 to

½ systemic pressure with an arterial oxygen saturation no less than 75% on 40% FiO2.

9. The constriction site of the band is secured with a hemoclip or permanent sutures.

10. The band is secured to the adventitia of the main pulmonary artery.

11. Assess hemostasis.

12. Mediastinal blake drain placement and closure of the pericardium.

13. Sternotomy closure.

Potential Complications and Pitfalls

1. Excessive banding may result in unacceptable cyanosis and hemodynamic collapse.

2. Inadequate banding may lead to persistent pulmonary overcirculation, possible pulmonary vascular disease and

failure to thrive.

3. Placing the band too proximally can result into an incompetent pulmonary valve. This can also pose a problem during

the debanding procedure. The sinus portion of the pulmonary artery often needs to be patched during the de-banding

operation.

4. To avoid the band migration, the band should be sewn to the adventitia of the pulmonary artery. Band migration

causes narrowing of the bifurcation and/or kinking/obstruction of the right pulmonary artery.

5. Damage from the band: Band material can potentially cut through the pulmonary artery and produce hemorrhage.

6. In case of difficulty in passing the band around the pulmonary artery, the ‘subtraction technique’ can be used to

facilitate placement of the band around the pulmonary artery. The band is first passed around both the pulmonary

artery and the aorta through the transverse sinus and then passed between the pulmonary artery and the aorta. This

maneuver avoids passing a right angle solely around the friable pulmonary artery.

Template Dictation

Preoperative diagnosis: [Blank]

(Possible Indications –Swiss cheese ventricular septal defect, tricuspid atresia with normally related great vessels with

pulmonary overcirculation, multiple ventricular septal defects with coarctation)

Postoperative diagnosis: Same

Procedure(s) Performed: Pulmonary artery banding

Attending Surgeon: [BLANK]

Secondary Surgeon: [BLANK]

Assistants: [BLANK]

Anesthesia: [BLANK]

Indication(s) for Procedure: [Age] week old [Gender] with history of [Complaint/Diagnosis].

Description of the Procedure: The patient was brought to the operation room on [Date]. The patient’s identity and planned

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procedure were verified and the patient was placed supine on the operating table. General anesthesia was administered.

Monitoring lines and foley catheter were placed. The chest and abdomen were prepped and draped in the usual sterile manner.

A time out was performed. A median sternotomy was then performed. A total/subtotal thymectomy was performed. The

pericardium was opened in the midline and a pericardial cradle created.

The patent ductus arteriosus was dissected out, ligated and divided (if present). The aorta and the pulmonary artery were then

separated with cautery. The main pulmonary artery was then encircled circumferentially by blunt dissection [Variation: If

difficulty is encountered while dissecting the main pulmonary artery the ‘subtraction technique’ can be used]. The banding

material [Options: Teflon impregnated Dacron, Silastic or 3mm ePTFE] is passed around both the aorta and the pulmonary

artery in the transverse sinus. The aorta is then dissected and the band was brought in between the pulmonary artery and the

aorta. The band is sequentially tightened using hemoclips or 5-0 prolene sutures [Note: The approximate circumference of the

band is determined using the Trusler’s formula: 20mm+child’s weight in kilograms]. Once the distal pulmonary artery pressure

was reduced to 1/3 to ½ systemic pressure and the systemic arterial saturation was greater than 75% on 40% inspired oxygen

the constriction site of the band was secured with a hemoclip or 5-0 prolene suture. With this a 10-15 mm of Hg rise in

systemic arterial pressure was seen. The band was then secured to the adventitia of the main pulmonary artery using 6-0

prolene suture.

Hemostasis was confirmed. A mediastinal blake drain was placed. The median sternotomy was closed with stainless steel

wires. The fascia was closed using 2-0 vicryl, the subcutaneous tissue using 3-0 vicryl and the skin was approximated using 4-

0 vicryl in a subcuticular manner. Sterile dressing was applied to the incision.

All the needles, sponges and instruments counts were found to be correct at the end of the procedure. The patient was

transferred to the intensive care unit in a stable condition.

Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.

13. Modified Blalock-Taussig Shunt (Using Interposition Gore-Tex

Tube Graft)

Muhammad Aftab, MD, Ismael Alejandro Salas De Armas, MD, Carlos M. Mery*, MD, MPH

Baylor College of Medicine/Texas Heart Institute, Houston, TX

*Texas Children’s Hospital/Baylor College of Medicine, Houston, TX

Essential Operative Steps

1. Lines and Monitoring.

2. General endotracheal anesthesia.

3. Left radial/femoral/pre-existing umbilical arterial line.

OPTION A: RIGHT THORACOTOMY

A4. Left lateral decubitus position.

A5. Serratus-sparing right posterolateral thoracotomy.

A6. Enter left pleural space through 4

intercostal space.

A7. Retract the lung inferiorly and posteriorly for an optimal exposure.

A8. Doubly-ligate and divide the azygos vein.

A9. Open the mediastinal pleura posterior to the SVC and right phrenic nerve.

A10. Dissect behind the SVC until the right pulmonary artery and its branches are identified.

Circumferentially dissect the right pulmonary artery and its branches (perform the proximal dissection under the

ascending aorta).

A11. Identify the right subclavian artery on the apex of the pleural cavity and circumferentially dissect the

artery with care not to injure the right recurrent laryngeal nerve.

OPTION B: MEDIAN STERNOTOMY (NO CPB)

B4. Supine position.

B5. Median sternotomy and thymectomy.

B6. Open the superior portion of the pericardium and distract with stay sutures.

B7. Dissect the innominate artery, right carotid artery, and right subclavian artery with care not to injure the recurrent

laryngeal nerve.

B8. Dissect the right pulmonary artery under the ascending aorta and SVC. Continue the dissection to include the first

branches of the right pulmonary artery.

THORACOTOMY/STERNOTOMY

1. Select 3/3.5/4 mm Gore-Tex shunt and trim appropriately.

2. Systemic heparinization 100 IU/Kg (1 mg/Kg).

3. Control the right subclavian artery with atraumatic snares or a side-biting clamp. [If through a sternotomy,

control the innominate artery, the right carotid artery, and the distal right subclavian artery].

4. A longitudinal incision on the inferior surface of the right subclavian artery to correspond to the size of the shunt.

5. An end-to-side shunt to subclavian artery anastomosis with fine poplypropelene suture.

6. Deair the shunt with heparinized saline solution.

7. Control the shunt with a clamp.

8. Unclamp the subclavian artery [innominate artery/right carotid artery].

9. Assure hemostasis at the anastomotic site.

10. Snare the proximal right pulmonary artery with an atraumatic snugger and control the branches with Silastic

vessel loops or atraumatic snuggers.

11. Make a longitudinal incision on the superior surface of the right pulmonary artery with care not to enter the right

upper lobe branch of the artery.

12. Create an end-to-side shunt to pulmonary artery anastomosis with fine polypropelene suture.

13. Remove the pulmonary artery snare and vessel loops.

14. Remove the clamp from the shunt.

15. Ensure hemostasis and check for a thrill.

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16. [If through a median ste rnotomy, may ligate the patent ductus arteriosus].

17. Irrigate with warm antibiotic saline irrigation.

18. Place an appropriate drain.

19. Chest closure

Potential Complications and Pitfalls

1. Modified Blalock-Taussig shunts can be performed through right or left posterolateral thoracotomies or through a

median sternotomy. The approach depends on the anatomy of subclavian and pulmonary artery, the presence and

location of the ductus arteriosus, the relationship of the great vessels, and surgeon/institutional preference.

Advantages of a thoracotomy approach include the ability to place the shunt more distally in the subclavian artery

potentially allowing for better control of pulmonary blood flow and the lack of mediastinal adhesions for future

operations. Advantages of a sternotomy approach include less technical challenge and the ability to control the ductus

arteriosus at the same time. If the patient is marginally stable, a median sternotomy approach with cardiopulmonary

bypass may be necessary.

2. Special attention should be paid to avoid any inadvertent injury to the phrenic and recurrent laryngeal nerves during

the dissection.

3. The right pulmonary artery should be clearly identified and circumferentially dissected. The right pulmonary artery

should be dissected medially up to the location of the main pulmonary artery and laterally onto the first branches.

The branches of the right pulmonary artery should be adequately identified in order to avoid placing the shunt into the

right upper lobe branch.

4. The size of Gore-Tex graft is determined based on the size of the patient, the length of the shunt, and its location.

Generally, when creating a shunt through a median sternotomy, a 3.5 mm shunt is used for most patients except for

those <2.5 kg (3 mm shunt) or >4 kg (4 mm shunt). When creating a shunt through a thoracotomy, a 4 mm shunt is

usually appropriate as the size of the subclavian artery will control the amount of flow into the shunt.

5. The graft should be trimmed to an accurate length. Too short of a graft will cause tension on the anastomosis leading

to bleeding along the suture line, distortion of the pulmonary artery with resultant stenosis and possible thrombosis.

Similarly, too long of a graft may cause kinking and distortion of the pulmonary artery and possibly compromise shunt

flow.

6. At the completion of anastomosis, oxygen saturation should increase and diastolic blood pressure should decrease. A

palpable thrill should be present in the shunt and the distal pulmonary artery. In patients with a very large ductus

arteriosus that are undergoing a shunt through a contralateral thoracotomy, there may not be marked changes in oxygen

saturation or diastolic blood pressure upon unclamping of the shunt.

7. Bleeding from the suture line is controlled by packing the anastomotic site lightly with Gelfoam soaked with topical

thrombin or Surgicel for a few minutes. Protamine administration to reverse the heparin is usually avoided, unless

there is excessive bleeding.

8. It is imperative to maintain an adequate systemic arterial pressure prior, during, and after the procedure to avoid early

shunt thrombosis.

9. Aspirin or low-dose intravenous heparin are routinely administered and continued postoperatively to prevent shunt

thrombosis.

Template Dictation

Preoperative Diagnosis: [BLANK]

Postoperative Diagnosis: [BLANK]

Procedure(s) Performed: Creation of right modified Blalock-Taussig shunt with [BLANK] mm Gore-Tex graft via right

thoracotomy/median sternotomy.

Drainage: Right pleural/mediastinal chest tube.

Attending Surgeon: [BLANK]

Secondary Surgeon: [BLANK]

Assistants: [BLANK]

Anesthesia: [BLANK]

Indication(s) for Procedure: This is a [BLANK]-day-old, [BLANK] kilogram, full-term neonate with a pre-natal/post-natal

diagnosis of [BLANK]. He was started on intravenous prostaglandins and transferred to the Neonatal Intensive Care Unit. An

echocardiogram confirmed the diagnosis of [BLANK]. The branch pulmonary arteries were of good caliber and were

confluent. He was felt to be an appropriate candidate for staged single ventricle palliation and is put forward now for

placement of a systemic-to-pulmonary artery shunt.

Operative Findings: The right pulmonary artery and its branches were of adequate size. The right subclavian artery was of

adequate size. The oxygen saturation and blood pressure responded as expected after placement of the shunt. There was a

palpable thrill on the shunt and right pulmonary artery at the end of the procedure.

Description of the procedure: After obtaining appropriate consent, the patient was brought to the operating room and placed

in a supine position. Single lumen general endotracheal tube anesthesia was induced and necessary monitoring lines, including

a left radial arterial line, were placed (Variation: The patient was brought from the Intensive Care Unit with umbilical arterial

and venous catheters in place).

RIGHT THORACOTOMY:

The patient was turned into the left lateral decubitus position and the right chest was prepped and draped. A serratus-sparing

right posterolateral thoracotomy incision was performed and the pleural space was entered through the fourth intercostal space.

The lung was retracted inferiorly and posteriorly. The azygos vein was doubly ligated and divided. The right pulmonary

artery was identified and was circumferentially dissected distally onto the first branches. The right subclavian artery was

identified medial/lateral to the recurrent laryngeal nerve, and was circumferentially dissected.

MEDIAN STERNOTOMY:

The patient was prepped and draped. A median sternotomy was performed. A thymectomy was undertaken. The upper

pericardium was opened longitudinally and a series of pericardial stay stitches were placed in order to facilitate exposure.

The innominate artery, right carotid artery, and right subclavian artery were dissected with care not to injure the recurrent

laryngeal nerve. The right pulmonary artery was dissected up to its first branches.

THORACOTOMY/STERNOTOMY:

A [BLANK] mm Gore-Tex shunt was selected and tailored appropriately. Systemic heparin was administered at 100 IU/kg

(1mg/kg). The right subclavian artery [, right carotid artery and innominate artery] was/were controlled with a vascular

clamp/atraumatic snuggers. A longitudinal incision was made on the inferior surface of the right subclavian artery. An end-to-

side graft to subclavian artery anastomosis was performed using running fine polypropylene suture. The shunt was deaired and

controlled with a clamp. The clamp/snuggers was/were removed from the subclavian artery [, carotid artery and innominate

artery]. Hemostasis was assured at the anastomotic site. The proximal right pulmonary artery was snared with an atraumatic

snugger. The branches were controlled with silastic vessel loops. A longitudinal incision was made on the superior surface of

the right pulmonary artery and an end-to-side shunt to pulmonary artery anastomosis was performed using running fine

polypropylene suture. The pulmonary artery snare and the vessel loops were removed and the shunt was de-aired through the

suture line. The clamp was then removed from the shunt, and there was an appropriate fall in mean and diastolic arterial

pressure. There was a thrill in the shunt. Excellent hemostasis was assured. The incision was irrigated with warm antibiotic

saline irrigation. A single right pleural/mediastinal chest tube was placed. [The rib edges were re-approximated using

interrupted absorbable pericostal sutures. Serratus anterior fascia, latissimus dorsi muscle, and subcutaneous tissue

were re-approximated using running absorbable suture.] [The pericardium was loosely reapproximated. The sternum

was reapproximated with interrupted stainless steel wire. The fascia and subcutaneous tissues were re-approximated

with running absorbable suture] The skin edges were approximated using a running absorbable subcuticular stitch.

Dermabond skin adhesive was applied. The patient tolerated the procedure without complications. He/She was left intubated

and was transported to the Pediatric Cardiac Intensive Care Unit in satisfactory condition.

Needles, sponges and instruments counts were correct at the end of the procedure.

Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.